Believe Yoga

Believe Yoga

Disclaimer and health screening form
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency contact

Area Code Phone Number
Medical History
Have you ever had any of the following health conditions

Asthma or Breathing problems Low Blood Pressure High Blood Pressure Diabetes Dizziness/ fainting or vertigo Circulatory problems Epilepsy/seizures Heart problems
Are the health conditions past or active medical history
How would you rate your current health status?
Do you have any current injuries?

Yes No
If Yes please specify
Have you ever suffered from any of the following injuries?

Neck or spinal injury Lower back injury Joint injury (hip, ankle, knee, shoulder, elbow) Muscular injury
Please detail your injury below ...
Please be aware if practicing yoga with any injury that you stop if you are in any pain. Yoga should not be painful or cause strain or stress to the body.
Yoga for you
Do you practice yoga for any of the following reasons

Stress reduction Mental clarity Mindfulness (being in the here and now) Spiritual reasons / connection / enlightenment Overall well-being Confidence Self-control Weight management Flexibility and strength Managing a particular condition (please specify below)
Specify...
Are you pregnant?

Yes No
Are you active on a daily basis?

Yes No
Do you engage in any of the following exercise?

Running Walking Cycling Swimming Weight Lifting High intensity interval training/ boot camp Pilates
Disclaimer: If at any time during the practice you experience discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body and respect its limites on any given day. Please read the statement below and sign if you are happy to continue I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. I should consult a GP prior to begining in any activity or yoga programme.I recognise that it is my responsibility to notify my teacher of any serious illness or injury before the yoga class. I will not perform any postures to the extent of strain or pain. I will practice at my own ability at all times. I understand that as with any physcial activity there is a risk to physical injury. I acknowlege I have been asked to consult with my GP before beginning yoga and therefore accept full responsibility to any possibility of injury from the class. I accept that neither the instructor, nor the hosting facility is liable for any injury or damages to person or property resulting from taking the class. Signature (for the disclaimer)

Clear
Name

First Name Last Name
Should be Empty:

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Believe Yoga

Medical History

Please be aware if practicing yoga with any injury that you stop if you are in any pain. Yoga should not be painful or cause strain or stress to the body.

Yoga for you